COMBINING DATA SOURCES TO EVALUATE HIV HOUSING PROGRAMS: EXAMPLES

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1 COMBINING DATA SOURCES TO EVALUATE HIV HOUSING PROGRAMS: EXAMPLES FROM NEW YORK CITY HOPWA John Rojas, MPA, Director of Administration and Housing Laura Hollod, MPH, Senior Analyst New York City Department of Health and Mental Hygiene Eastern Region Supportive Housing Conference March 27-28, 2014 Philadelphia, PA

2 53,615 Homelessness in NYC Average daily census of homeless shelter system, January ,180 Estimate of street homelessness, ,926 Persons living with HIV/AIDS (PLWHA) who resided in transitional housing in PLWHA in January ,842 PLWHA cycling through HIV emergency housing (i.e., Single Room Occupancy hotels) in ,085 PLWHA in January

3 HIV/AIDS in NYC In 2012, there were 114,926 PLWHA living in NYC, including 3,141 new diagnoses.

4 HIV Housing Resources in NYC Department of Health and Mental Hygiene (DOHMH) is the administrator of several federally-funded HIV grants: Housing Opportunities for Persons with HIV/AIDS (HOPWA): $53M in 2013 Ryan White Part A: $102M in 2013; $10M allocated for housing HIV/AIDS Services Administration (HASA) provides welfare and rental assistance to lowincome PLWHA ~35,000 PLWHA enrolled in 2013

5 Housing Opportunities for PLWHA Rental Assistance Rent subsidies to help establish and/or maintain affordable housing Housing Placement Assistance Assistance to locate, acquire, finance, and maintain affordable housing Supportive Housing Affordable housing + comprehensive support services HOPWA program support services promote health and housing stability, emphasizing engagement in HIV primary care.

6 Data Sources for Evaluation Program Database Enrollments, services, behavior and demographics for persons living with HIV and their family members accessing HIV housing services HIV Surveillance Registry HIV diagnosis information and laboratory tests (CD4 counts and viral loads) for persons diagnosed with or receiving HIV care in NYC Housing Databases Addresses and housing type for persons living with HIV accessing housing services HIV Housing Program Evaluation Dataset

7 Program Reporting and Quality Improvement HOPWA providers report to DOHMH Demographics HIV primary care visits and laboratory test results Enrollment details Services provided DOHMH regularly analyzes data to monitor and improve services Housing retention HIV health care HIV primary care Viral suppression Antiretroviral treatment (ART) Service provision DOHMH provides feedback to HOPWA providers Electronic dashboards and one-click reports Provides metrics to identify clients not engaged in HIV care and/or services

8 Research and Evaluation: Examples Randomized controlled trial to evaluate models of housing placement assistance for PLWHA residing in emergency shelters Longitudinal analyses of housing and HIV health care outcomes among PLWHA receiving different housing services Evaluation of patterns of homelessness and associated factors, among PLWHA receiving public assistance

9 HIV Care Continuum Visual depiction of the continuum of HIV care and treatment for PLWHA Developed by the US Centers for Disease Control and Prevention (CDC) Important national policy tool for measuring success of the HIV health care system NYC HOWPA combined program and surveillance data to generate a continuum of care specific to HOPWA Supportive Housing

10 United States HIV Care Continuum 80% of diagnosed 45% of diagnosed 40% of diagnosed 30% of diagnosed US: The largest drop is from linked to care to retained in care. Source: Centers for Disease Control and Prevention. CDC Fact Sheet: HIV in the United States: The Stages of Care. July Accessed 20 September 2013 at

11 NYC HOPWA Supportive Housing HIV Care Continuum, % 90% 80% 70% 5,948 5,937 5, % 99.8% 98% 5,505 93% 4,044 60% 50% 68% 40% 30% 20% 10% 0% Enrolled in HOPWA in 2012 Ever linked to HIV care Engaged in HIV care in 2012 Presumed ever started on ART Suppressed VL ( 200 copies/ml) HOPWA: The largest drop is from ever started ART to suppressed in As Data reported to to the NYC New DOHMH York City as of Department June 30, of Health and Mental Hygiene by June 30, 2013.

12 NYC HOPWA Supportive Housing Evaluation Do PLWHA placed in HOPWA supportive housing have improved housing and HIV health care outcomes? Do these outcomes improve at a different rate compared to a control group?

13 Supportive Housing Evaluation: Methods Treatment group: PLWHA placed in HOPWA supportive housing (N=1,893) No prior exposure in Comparison group: PLWHA receiving HOPWA services in , but no supportive housing between (N=27,464) Arbitrary baseline assigned for pre/post comparison Compared outcomes pre- and post-placement Days spent in emergency housing Retention in HIV care Viral suppression Statistical methods used Continuous variable: paired T-test; multivariate linear regression Binary variables: McNemar s test; conditional logistic regression

14 Supportive Housing Evaluation: Results Mean days in emergency housing Supportive housing No supportive housing Pre Post

15 Supportive Housing Evaluation: Results PLWHA placed in supportive housing spent significantly fewer days in emergency housing vs. the year preplacement Mean = 119 fewer days (95% CI ) The comparison group experienced no difference in days spent in emergency housing Mean = 0 fewer days (95% CI 0 1 days); p=0.27 Improvement among the supportive housing group was significantly greater vs. the comparison group Linear regression (p<0.0001); multivariate linear regression (p<0.0001) controlling for important variables (age, race/ethnicity, sex, HIV transmission risk, AIDS diagnosis, country of birth)

16 Supportive Housing Evaluation: Results Enrolled in supportive housing Not enrolled in supportive housing 100% 92% 90% 83% 80% 70% 82% 86% 67% 69% 60% 50% 49% 55% 40% Retention in care Viral suppression Pre Post Pre Post Both groups experienced significant improvements in retention and viral suppression Improvement rate for retention was significantly higher for the supportive housing group vs. the comparison group (p<0.0001); no difference for viral suppression (p=0.12) Conditional logistic regression controlling for important variables (retention p<0.0001; viral suppression p=0.11) Both pre- and post-placement, PLWHA in supportive housing had lower viral suppression

17 Summary Merging various data sources provides DOHMH with a robust dataset for HOPWA program evaluation HOPWA clients have strong engagement in HIV care HOPWA program emphasis on promoting HIV care DOHMH quality improvement initiatives HOPWA clients are more likely to fall off the HIV care continuum with ART use and viral suppression Low-income Minority Co-occurring conditions, e.g., mental illness, substance abuse HOPWA supportive housing clients experienced improved nearterm housing stability, retention in care, and viral suppression Even after placement, viral suppression still remains lower than that for PLWHA not placed in supportive housing

18 How can NYC HOPWA Close the Gaps? Identify factors impacting viral suppression among stably-housed PLWHA Continue to emphasize engagement in HIV health care and treatment among clients in HOPWA housing Examine models of housing and support that promote optimal housing and HIV health care outcomes, especially within vulnerable populations Enhance holistic approach to addressing clients needs including mental health and substance use services which impact both health and housing outcomes

19 Program/Policy Implications Use evaluation data to inform policy-makers on successful HIV and housing outcomes among HIV housing clients Funding and legislation Highlight the usefulness of surveillance data for program evaluation of housing services Integrate housing into mainstream surveillance analyses Identify best practices successful program models to replicate and disseminate within HIV community Make recommendations on policy and program design that strengthen the link between housing services and HIV care continuum success

20 Contact Info John Rojas, MPA Director of Administration and Housing Laura Hollod, MPH Senior Analyst

21 Acknowledgements Persons living with HIV/AIDS in NYC NYC HIV housing service providers NYC DOHMH Bureau of HIV/AIDS Prevention and Control Housing Services Unit Epidemiology and Field Services Unit Care & Treatment Unit

22 Sources cited 1. NYC Department of Homeless Services and Human Resources Administration and NYCSTAT, shelter census reports. 2. NYC Department of Homeless Services. Homeless Outreach Population Estimate Results Unpublished NYC HOPWA program data. 4. NYC Human Resources Administration. HASA Facts.

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